IMCOM Form 44 Application for Survivor Access Card

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APPLICATION FOR SURVIVOR ACCESS CARD

OMB CONTROL NUMBER: 0702-SACA

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0702-SACA, is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT OF 1974

AUTHORITY: 5 U.S.C. 301; Department Regulations; 10 U.S.C. 3013, Secretary of the Army; Section 626 of the National Defense Authorization Act (NDAA) For Fiscal Year 2019, Access to Military Installations for Certain Surviving Spouses and other Next of Kin of Members of the Armed Forces Who Die While on Active Duty or On Certain Reserve Duty; Army Regulation 190-13, The Army Physical Security Program

PURPOSE: To provide installation commanders and law enforcement officials with the means by which information may be accurately identified to determine if an applicant meets authorized access requirements.

ROUTINE USES: The “Blanket Routine Uses” set forth at the beginning of the Army’s compilation of System Records Notices apply to this system.

DISCLOSURE: Voluntary; however, failure to provide the requested information may result in denial of access to U.S. Army Installations.

SECTION I- APPLICANT INFORMATION

Full Name (Last, First, Middle): Date of Birth (YYYY/MM/DD):

Current Resident Address :

City: State: Zip Code:

Home Phone No: Cell Phone No:

E-mail Address:

Driver License Number: State of Issuance:

In Honor of Service Member:

Relationship to Service Member: Rank of Service Member:

_____________________________________ ____________________________________ ________________

Applicant Printed Name Applicant Signature Date

Applicant Certification: I certify the information provided is true and accurate, and I am providing it with the purpose of receiving the Survivor Access Card. I understand I must give ______________________________Visitor Control Center (VCC) consent to conduct a criminal history screening prior to the issuance of a Survivor Access Card. Failure to do so will result in the termination of the application process. I understand that this background screening will determine my eligibility for access onto Army installations.

_____________________________________ ____________________________________ ________________

Applicant Printed Name Applicant Signature Date

SECTION II- APPLICANT DOCUMENTATION REQUIREMENTS

State Photo Identification Card or Passport

Present proof of ID in person at time of ID card issue

Applicants are required to provide proof of identity in original form, in person, at time of Survivor Access Card issue

IMCOM FORM 44 Controlled by: IMCOM, G9, Family Programs Page 1 of 3 CUI Category: PRVCY

POC: [email protected]

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SECTION III- PHYSICAL SECURITY OFFICE VERIFICATION

(For Physical Security Office use only)

Date of NCIC III check: Is applicant cleared for unescorted access:

If No; reason: Derogatory information in report: ;More information is needed:

Name of Government personnel performing Fitness Determination:

Signature of Government personnel performing Fitness Determination:

Phone number of Government personnel performing Fitness Determination:

SECTION IV- SURVIVOR OUTREACH SERVICE VERIFICATION

IS APPLICANT CLEARED FOR CARD ISSUANCE:

Installation of Survivor Outreach Service Office:

Survivor Outreach Services’ Official Signature: Date:

Expiration Date of Survivor Access Card:

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Survivor Access Card FAQs

1. Who is eligible for the Survivor Access Card?

Eligible Surviving Family members are those who meet the criteria to receive the Gold Star Lapel Button or Gold Star Next of Kin Lapel Button to include widow or widower, each parent, each child, stepchild, child through adoption, brother, half–brother, sister and half–sister.

2. How long is the Survivor Access Card valid?

The Survivor Access Card (SAC) is valid for three years (NCIC III check date has to be listed on the card) at all Army Installations and may be renewed upon expiration. Expired SAC are required to be turned in before the issuance of a new SAC. New applicants and vetting process is required for all lost and expired cards. Must be 18 years of age or older to apply.

3. Am I required to undergo a background check for the Survivor Access Card?

Yes, all applicants are required to go through a Physical Security Determination by their local Visitor Control Center. Your nearest Survivor Outreach Service Coordinator will assist with this process.

4. What are the entitlements associated with the Survivor Access Card?

The Survivor Access Card is intended for recognition and installation access to receive services, attend events, view memorial, and similar activities. The Survivor Access Card does not provide additional benefits or entitlements not already authorized to eligible Surviving Family members.

5. Who can I contact for additional information and to initiate the process?

The Army has a network of Survivor Outreach Service Coordinators at various locations. Contact the Survivor Outreach Service Coordinator at the installation closest to you by using the Survivor Outreach Service Staff finder located at https://dcsg9.army.mil/safr/sos/sos-find.html.

Survivor Access Card Application Procedures

1. Complete the Survivor Access Card Application Form (Form Number 44) and sign the Applicant Certification.

2. Submit all completed documents to the closest Army installation Survivor Outreach Service Coordinator.

3. The installation Survivor Outreach Service Coordinator will review the request and verify eligibility.

4. The installation Survivor Outreach Service Coordinator forwards the request to installation access control for screening of a Physical Security Determination.

5. The installation Survivor Outreach Service Coordinator will contact you upon completion of the Physical Security Determination for further coordination of the Survivor Access Card.

6. Upon successful vetting, the Survivor Access Card will be issued for a 3-year period by the installation Visitor Control Center.

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